Guideline for the Management of Conjunctivitis in Children >1 month-16 years

• Summary
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• Background
• Clinical Diagnosis
• Investigation
• Treatment
• Non-Antimicrobial Treatment
• Empirical Antimicrobial Treatment
• Directed Antimicrobial Treatment (when microbiology results are known)
• Duration of Treatment
• Treatment Failure

History
Rapid onset, red, sticky eye(s), usually starts in one eye then spreads to the other.
Pain, photophobia and rapidity of onset are markers of severity.
Older children may report “gritty” sensation.
Close contact with another infected person is common; eyes are often stuck together by discharge after sleep.

For neonates with conjunctivitis see Guideline for the management of neonatal conjunctivitis (ophthalmia neonatorum)

Examination

• Assess for purulent discharge with crusty lids – clean the eye to enable examination for diffusely injected conjunctiva.
• Check for ciliary injection: redness and dilated blood vessels between the white of the eye and the iris (suggests inflammation of deeper structures)
• Check for pain on eye movement (a feature of orbital cellulitis)
• Assess lymph nodes in front of the ear.
• Massage nasolacrimal duct at side of nose to check for regurgitation of pus (if present, the likely diagnosis is blocked tear duct; clean eye, no antibiotics unless skin infection, probe after 1 year of age unless abscess).
• Chronic conjunctivitis (see below) requires slit lamp examination.

Exclude other serious causes of a red eye – see diagnosis section of full guideline, then
Assess if:
Hyperacute conjunctivitis: sudden onset (<24 hours) and rapid progression of profuse discharge (usually young adults); preauricular lymphadenopathy often present.

Acute severe conjunctivitis: symptoms <3 weeks duration; red eye, mild/moderate discharge (subjective clinical assessment) AND any of severe pain; photophobia; or severe eyelid oedema.

Acute non severe conjunctivitis: symptoms <3 weeks duration; red or pink, gritty eye, minimal/moderate discharge; no photophobia; minimal pain.

Chronic conjunctivitis: symptoms >3 weeks duration.

If periorbital cellulitis is present or eye movements are painful see LTHT guideline for diagnosis and management of orbital cellulitis.

Investigations

• Hyperacute conjunctivitis: eye swab for routine culture and APTIMA swab for gonococcal and Chlamydia nucleic acid detection.
• Slit lamp confirmed follicular conjunctivitis: APTIMA swab for Chlamydia nucleic acid detection.
• Chronic conjunctivitis with pre-auricular lymph node: APTIMA swab for Chlamydia nucleic acid detection.
• (N.B. Chronic blepharitis does not require APTIMA swab for Chlamydia nucleic acid detection).
• Acute non-severe conjunctivitis: eye swab is unnecessary.
• Acute conjunctivitis not responding to topical antimicrobials: eye swab for routine culture.
• Acute severe conjunctivitis: eye swab for routine culture.

Non-antimicrobial treatment

• Advise condition is contagious.
• Advise the use of different towels between household members.
• For infants who attend nursery, advise returning to nursery only when the infection is fully cleared because of the infection risk to others.
• Children who wear contact lenses should remove lenses until all symptoms of infection have resolved and for at least 24 hours after the treatment has been completed.
• Lubricant eye drops/gel to reduce discomfort. Hypromellose 0.3% drops or Carbomer 0.2% eye gel instilled three to four times a day or more often are suitable lubricants.
• Secretions from the lid and lashes should be removed with cotton wool soaked in water.

Antimicrobial treatment
Topical antimicrobials should not be routinely used for acute non severe conjunctivitis because it is a self-limiting disease.  Review inpatients (or advise outpatients to return if no better) in 3 days.

For acute severe infection chloramphenicol 0.5% eye drops or chloramphenicol 1% eye ointment is first line empirical treatment.  Fusidic acid 1% (Fucithalmic®) eye drops are used in patients who are allergic/intolerant to chloramphenicol, are pregnant or have a personal or family history of blood dyscrasias.

Hyperacute conjunctivitis or other suspected Neisseria gonorrhoeae infection – see empirical treatment section.

Referral criteria
Refer urgently to ophthalmology:

• Any conjunctivitis with severe pain or photophobia despite frequent lubricants, features of deep inflammation or orbital cellulitis.
• Any patient suspected to have Stevens-Johnson syndrome.
  Refer non-urgently to ophthalmology:
• Any patient with chronic conjunctivitis.

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Infective conjunctivitis is usually a self-limiting condition which resolves within 2 weeks. It may be viral or bacterial. Bacterial conjunctivitis is most commonly caused by Staphylococcus species, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 
It can be difficult to differentiate bacterial from acute viral conjunctivitis and many cases of acute infective conjunctivitis are treated as bacterial on clinical grounds.

Gonorrhoea and Chlamydia may also cause infection in sexually active patients. 

Infective conjunctivitis can be classified into 4 types to guide investigation and treatment:

1. Hyperacute conjunctivitis is a distinct clinical entity characterised by the development of a copious, purulent discharge over 12 to 24 hours. It is the most serious cause of conjunctivitis and occurs in neonates (ophthalmia neonatorum) but may also occur in sexually active adolescents and young adults.  Neisseria gonorrhoeae is the usual cause. These patients should be swabbed, treated systemically and then referred urgently to ophthalmic specialists because infection can rapidly progress to ulceration and perforation (within 24 hours) – see relevant sections of the full guideline.

2. Acute severe conjunctivitis is moderately common. It is usually caused by adenovirus but sometimes severe conjunctivitis may be due to infection with Neisseria gonorrhoeae or occasionally Neisseria meningitidis, as well as the common bacterial pathogens listed above. It is characterised by symptoms <3 weeks duration; red eye; mild/moderate discharge (subjective clinical assessment) AND any of severe pain; photophobia; or eyelid oedema.

3. Acute non-severe conjunctivitis is defined by: symptoms <3 weeks duration; red or pink, gritty eye, minimal/moderate discharge, no photophobia and minimal pain. It may be caused by bacterial or viral infection and is usually self-limiting lasting no longer than 3 weeks.

4. Chronic infective conjunctivitis by definition lasts longer than 3 weeks. It is commonly associated with blepharitis and Chlamydia infection.  One occasional cause of chronic conjunctivitis is molluscum contagiosum.

There are locally adapted definitions.

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Conjunctivitis presents as an acute, red, gritty, sticky eye(s), usually bilateral but may be sequential; purulent discharge with crusty lids and diffusely injected conjunctiva.  The rapidity of progression and severity of symptoms determines classification, treatment and investigation - see background.

With a unilateral red eye it is important to exclude serious causes e.g. glaucoma, keratitis and iritis.  These should be suspected if any of the following features occur:

• Moderate to severe ocular pain or photophobia,
• Marked redness of the eye in one eye.  The greater the redness, the more likely that the cause is serious. Ciliary injection, which is not always obvious, occurs with inflammation of deeper structures. It is indicated by redness and dilated blood vessels seen between the white of the eye and the iris.
• Reduced visual acuity as measured on a Snellen chart.

If there are NO features to suggest a serious cause of red eye exclude:-

• Superficial corneal injury.  Usually a history of trauma and an abrasion may be seen with fluorescein staining.
• Subconjuctival haemorrhage.  Apart from redness there are no other abnormal findings and the redness is well demarcated, does not cover the cornea and obliterates conjunctival blood vessels.
• Irritant conjunctivitis, which is usually associated with an identified mechanical or irritant cause.
• Allergic conjunctivitis.  This is usually associated itching and is recurrent following exposure to a known allergen.

The characteristic features of conjunctivitis are:-

• Close contact with another infected person
• Symptoms of upper respiratory tract infections are present.
• The eyes are glued together by discharge after sleep, or mucopurulent discharge is seen on examination.
• Conjunctivitis starts in one eye then spreads to the other.
• An enlarged lymph node in front of the ear is identified.

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Recommendation: For acute non-severe conjunctivitis swabs for microbiological investigation are generally unnecessary.  However swabs of the eye are recommended in acute severe and chronic conjunctivitis to identify the infective cause.
[Evidence level C]

Recommendation: In hyperacute conjunctivitis: send a swab for microscopy and bacterial culture and an APTIMA swab for gonococcal nucleic acid detection and a swab in viral transport medium for adenoviral PCR.
[Evidence level C]

Recommendation: In chronic conjunctivitis send a swab for bacterial culture and an APTIMA swab for Chlamydia nucleic acid detection.
[Evidence level C]

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Recommendation: Children who require contact lenses should not wear their lenses until all symptoms of infection have resolved and for at least 24 hours after the treatment has been completed.
[Evidence level C]

Recommendation: Lubricant eye drops/gel to reduce discomfort. Hypromellose 0.3% drops or Carbomer 0.2% eye gel instilled three to four times a day or more often are suitable lubricants.
[Evidence level C]

Recommendation: Secretions from the lid and lashes should be removed with cotton wool soaked in water.
[Evidence level C]

Recommendation: Removal of pseudomembranes: Very painful conjunctivitis can be caused by mucous membranes forming under the eyelids. Ophthalmology should assess for pseudomembranes and remove physically.
[Evidence level C]

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Recommendation: Topical antimicrobials should not be routinely used for non-severe acute conjunctivitis.
[Evidence level A]

Recommendation: Patients not prescribed topical antimicrobials should be advised to return or be reviewed in 3 days if symptoms are worse. Patients should be informed that viral conjunctivitis may take 7-12 days to resolve and bacterial conjunctivitis about 7 days without treatment.
[Evidence level C]

Recommendation: For acute conjunctivitis requiring treatment, first line therapy is chloramphenicol 0.5% eye drops (initially one drop is instilled into the affected eye(s) four times a day for 7 days) OR 1% eye ointment (applied three times a day for 7 days.)
[Evidence level C]

Recommendation: For patients who are allergic/intolerant to chloramphenicol, are pregnant, have a history, or family history of blood dyscrasias or would prefer a twice daily treatment fusidic acid 1% (Fucithalmic®) is an alternative.  A 7 course is recommended.
[Evidence level C]

Recommendations: For hyperacute conjunctivitis or confirmed gonococcal conjunctivitis prescribe topical treatment as above in addition to Cefotaxime (infants 1-3 months old) OR Ceftriaxone (infants 3 months – children 16 years old).

Cefotaxime dose:
Infants 1-3 months old: 50mg/kg  8 -12-hourly IV

Ceftriaxone * dose:
Patients under 50kg: 50mg/kg 24-hourly IV (maximum 1g)
Patients over 50kg: 1g 24-hourly IV (severe infection 2-4g 24-hourly)
*‘These does are different to the doses currently used in treating sepsis in Paediatric medicine’.

These doses should be given by intravenous infusion only, over 60 minutes.

A single dose only should be given if there is no corneal involvement.

If the cornea is involved, treatment should be for three days.

Justification
Bacterial conjunctivitis is usually a mild self-limiting disease with most patients being symptom free without treatment in one to two weeks.  Clinical cure/significant improvement occurred by days two to five in 65% (95% CI 59-70%) of those treated with placebo.¹

In a Cochrane review, Meta-analysis of early (days 2 to 5) and late (days 7 to 10) clinical and microbiological outcomes revealed that topical antibiotics are of benefit in improving early clinical (RR 1.24, 95% CI 1.05 to 1.45) and microbiological (RR 1.77, 95% CI 1.23 to 2.54) remission¹. These benefits were reduced but nonetheless persisted for late clinical (RR 1.11, 95% CI 1.02 to 1.21) and microbiological (RR 1.56, 95% CI 1.17 to 2.09) remission¹. No serious adverse outcomes were reported in either the active or placebo arms of the trials¹.  The authors conclude that although conjunctivitis is a self-limiting condition the use of antibiotics is associated with significant improved rates of clinical and microbiological remission although the advantages at day 6-10 is negligible.  There is further evidence that delaying treatment by 3 days and only prescribing if symptoms persist produces no difference in duration of moderate symptoms (3.3 days [risk ratio 0.7, 95% confidence interval 0.6 to 0.8], delayed antibiotics 3.9 days [0.8, 0.7 to 0.9]), but reduces antibiotic use².

Clinical Knowledge Summary (CKS) recommend that as most patients get better without treatment, complications are low and 10% of patients suffer adverse reactions to treatment that antibiotics should only be provided if:-

• Conjunctivitis is severe or likely to be severe, providing serious causes of red eye can be excluded.
• Despite the limitations the patient still prefers treatment.³

Third generation cephalosporins are the current treatment of choice for Neisseria gonorrhoeae infections as resistance rates are very low to these agents⁴.

In conclusion if conjunctivitis is mild it is worth not treating with antibiotics, prescribing lubricants and counseling patients on hygienic measures to prevent spread with a proviso to return if symptoms do not improve in 3 days.  For moderate to severe symptoms treatment should be prescribed.

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When the results of microbiology samples are known it may be necessary to amend therapy.  Discuss with microbiology as necessary.

Neisseria gonorrohoea or Neisseria meningitidis isolated - treat according to recommendations for gonococcal conjunctivitis.

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Acute conjunctivitis: 1 week.

Hyperacute conjunctivitis - see empirical treatment section.

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Recommendation: If conjunctivitis persists for more than two weeks the patient must be re-evaluated.

Referral to an Ophthalmologist should be considered to clarify diagnosis and rationalise therapy. Swabs for bacteria and Chlamydia should be taken, if not done already.  Treatment will depend on results of the swabs.  If Chlamydia is present the family must be referred to a community paediatrician for systemic treatment and child protection assessment.

For chronic conjunctivitis refer to an ophthalmologist.  N.B. Molluscum contagiosum will not resolve until the lesion is removed.

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